Global Burden of Disease data for Indonesia – Authors' reply
Authors: Nafsiah Mboi, Ali H Mokdad
Journal: The Lancet Global Health (2023)

We thank Christopher Maher and colleagues and Elizabeth Fitriana Sari and colleagues for their Correspondence regarding our recent Article.1GBD 2019 Indonesia Subnational CollaboratorsThe state of health in Indonesia's provinces, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Glob Health. 2022; 10: e1632-e1645Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar Their comments contribute to the scientific discourse on the burden of disease in Indonesia and provide us with an opportunity to engage further with the scientific community about our methods, results, and analysis. Maher and colleagues focus primarily on the data underpinning our estimates. We share the authors' concerns about data transparency and completeness, especially at the subnational level; therefore, in addition to ensuring GATHER compliance,2Stevens G Alkema L Black R et al.Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement.Lancet. 2016; 388: 19-23Summary Full Text Full Text PDF PubMed Scopus (523) Google Scholar we strive for maximum data transparency and acknowledge any data-weak areas. All data sources are listed in the appendix and are also accessible through several resources hosted online by the Institute for Health Metrics and Evaluation, including GBD Compare, Global Health Data Exchange, and our GitHub repository. Indeed, Maher and colleagues used these supplementary and corresponding resources to peruse the underpinnings of the study—an exercise that we welcome and encourage. We maintain that the benefits of reporting estimates comprehensively is a central tenet of the Global Burden of Disease, Injuries, and Risk Factors Study (GBD).3GBD 2019 CollaboratorsThe Global Burden of Disease Study 2019.Lancet. 2020; 296: 1129-1306Google Scholar Moreover, we go to great lengths to generate and report an uncertainty interval for each estimate in this paper so the user can interpret with precision. We are always the first to emphasise that the better the input data, the less modelling we will likely need, and have indeed seen iterative updates of subnational work in Indonesia spur the generation and sharing of data. Regarding the comments offered by Sari and colleagues, we acknowledge that the categorisation of tobacco into three types of risk factors—smoked, chewed, and secondhand smoke—is an insufficient schema to account for areca nut consumption. We also agree with Sari and colleagues that areca nut and betel quid are understudied despite the associated risk factors. The inclusion of areca nut and betel quid in our estimates would provide more nuanced and localised estimates on the burden of stimulants and narcotics in Indonesia and other countries where use of betel quid is common, especially India. As Sari and colleagues note, areca nut is consumed with and without tobacco (and usually mixed with a variety of other substances), and studies that measure areca nut use in south and southeast Asia have been done. However, most data for areca nut and betel quid consumption in Indonesia and elsewhere are noisy and unreliable. Studies such as the one that Sari and colleagues share help fill those gaps. We recognise the importance of producing accurate estimates of the health burden of areca nut use for countries with high rates of consumption like Indonesia and intend to include it in future GBD rounds. We declare no competing interests. Global Burden of Disease data for IndonesiaThe Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 Indonesia Subnational Collaborators1 provide national and provincial burden of disease estimates for Indonesia. We feel that more could have been done to alert readers to the sparsity of primary data underpinning these estimates—as is encouraged by the GATHER Statement2—to allow readers to make an "informed assessment of the completeness of the data amassed for the study".2 Full-Text PDF Open AccessGlobal Burden of Disease Data for IndonesiaThe Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment on incidence and prevalence of diseases, injuries, and risk factors.1 The GBD 2019 Indonesia Subnational Collaborators (November, 2022)2 used this extensive epidemiological database to analyse health patterns in Indonesia between 1990 and 2019. In this study, tobacco (smoked, chewed, and second-hand smoke) was included among the 87 risk factors examined. Strikingly, the list of risk factors does not include areca nut consumption. Full-Text PDF Open AccessThe state of health in Indonesia's provinces, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019Our findings highlight that Indonesia faces a double burden of communicable and non-communicable diseases that varies across provinces. From 1990 to 2019, Indonesia witnessed a decline in the infectious disease burden, although communicable diseases such as tuberculosis, diarrhoeal diseases, and lower respiratory infections have remained a main source of DALYs in Indonesia. During that same period, however, all-ages death and disability rates from non-communicable diseases and exposure to their risk factors accounted for larger shares of health loss. Full-Text PDF Open Access